Test 2 Flashcards
Supplies needed
•Local anesthetic agents
–Lidocaine
–Bupivicaine
–Ropivicaine
–+/- Epinephrine
•25-27 gauge needles (+/- 22 gauge)
•1mL syringes
Maximum dosage 2mg/kg total
Possible side effects
•Loss of feeling and function to the blocked area could lead to self trauma
•Anaphylactic reactions
•Permanent nerve damage
•Toxicity to the skeletal muscle
•Cardiac side-effects
Sites and landmarks
Rostral maxillary/infraorbital
•Caudal root of 3rd pm
Caudal maxillary
•Enter the foramen (not in cats or brachycephalics) or distal to 2nd molar
Rostral Mandibular “Mental”
•distal to the mandibular labial frenulum
•ventral to the mesial root of the 306, 406
–(2nd premolars)
Caudal Mandibular/Inferior Alveolar
•Draw an imaginary line from lateral canthus of eye as a landmark
Commissure
Area where lips meet
Labial frenulum
Area where lip attaches to the gingiva
Canthus
Corners of the eye
Lateral and medial
Who can perform a block
State law regulates if a technician able to perform*
Early signs of gingivitis
Gingivitis → Periodontitis
Initial signs to look for:
○Gingival bleeding (earliest sign)
○Halitosis (early sign)
■Plaque bacteria
Later:
○Calculus accumulated on the teeth - hardened plaque
○Bloody saliva/drool
+/-:
○Depression; changes in eating/chewing patterns
What does a healthy gingiva look like?
-Vital tissue, bright pink pigmented color with even smooth flowing gingiva from tooth to tooth (Topography)
●No bleeding on probing
●Normal gingival sulcus depth***
◦Canine 1-3mm (4mm) >5mm abnormal
◦Feline 0-1mm
Gum recession causes and outcome
●Gingival recession occurs due to periodontitis*
●Area where the roots join the crown and now exposed
●Classified by depth
◦Class 1 <1mm
◦Class 2 >1mm
◦Class 3 complete
Exposure of root furcation
- how to grade, record, chart
Measured by depth via probe
What PD really is
- other health effects
Left untreated, gingivitis progresses to periodontitis.
Initial signs of gingivitis:
○Gingival bleeding (earliest sign)
○Halitosis (early sign)
Periodontitis is caused by accumulating subgingival plaque and the body’s response to it
Plaque is made of bacteria, food debris, exfoliating cells, salivary glycoproteins
Plaque can mineralize within 24 hours
Periodontium consists of 4 structures*
1.Periodontal ligament
2.Gingival connective tissue
3.Alveolar bone (the tooth’s socket)
4.Cementum
“Free gingiva” forms a moat around the tooth = the gingival sulcus*
Periodontal Disease Index
Can be generalised or localized
Stage 0 - No disease Stage 1 (PD1) - Gingivitis - reversible, no attachment loss (AL*)
Stage 2 (PD2) - AL < 25% or furcation 1 exposure
Stage 3 (PD3) - AL 25%–50% or furcation 2 exposure
Stage 4 (PD4) - AL > 50% or furcation 3 exposure
*AL (Attachment Loss) is usually best based on measurements with a periodontal probe and intraoral radiographs.
The bacteria occurring in the mouth can colonize
•Liver
•Kidneys
•Heart
•Lungs
Stage 1 Periodontal Disease
Do you see the build up of tartar and the slightly swollen
and reddened gums - this is the first sign of pain!
Brushing the teeth now may be painful
Note that there is NO BONE LOSS!!
Stage 2 Periodontal Disease
The gums are swollen and the crown to the
right is worn down but not much else can be seen.
You may not see any significant swelling or redness of the gums. On X-rays there is 0 to 25% bone
loss. See how fuzzy the bone is here - it should be sharp. When it is fuzzy that means some of the
mineralization is gone
Stage 3 Periodontal Disease
More than 25% bone loss
Do you see where ‘a’ is? It looks totally normal but it is not normal under the gum line.
There is serious bone loss in this location. Do you see ‘a’ now? If you cannot see this bone loss when you look into your pet’s mouth
neither can your veterinarian. Only X-rays can find this bone loss. This is caused by
plaque under the gumline.
Stage 4 Periodontal Disease
More than 50% bone loss
~ This red line is where the bone level (white
on X-ray) should be.
This yellow line is where the bone actually is. Treatment: × - These teeth should be
extracted
Define prophylaxis
Are there more accurate terms
Prophylaxis (routine cleaning) performed on patients with stage 1-2 for prevention
Periodontal therapy performed on patients with stage 3-4 periodontal disease
COHAT is more accurate
Why do we need anesthesia
Anesthetic dentals are safer than ever with use of
–Throughout pre-op exams
–Pre-op b/w
–Multimodal analgesia helps reduce total anesthesia needed
–Individualized anesthesia plans
–Careful monitoring
–Warming devices
–CETT airway management
–Post-operative observation and monitoring
What about anesthesia- free cleanings
Ineffective and unsafe
Using sharp instruments in mouth
Why COHAT not prophylaxis?
Complete Oral Hygiene/health Assessment and Treatment
COHAT*
●Why is not to a dental “prophylaxis”?
–80% of pets between the ages of 1-3 years of age present with dental disease**
Client education examples
Client Education
•Starts with etiology of bacteria and explanation of periodontal disease
•Set realistic expectations
•Client compliance
▫Has much to do with making home care accessible/reasonable
•Client’s physical ability
•Patient tolerance
–Can be trained/conditione
- 80% of pets have PD
- Need anesthetized exam in order to examine throughly the patients mouth
- Need X-rays to look at roots for extractions fractures disease that are painful
- Calculus should be removed since it effects other body systems
- anesthesia is individualized for ea patient via BW+ P.E + Extraoral exam.
- IVC allows for CNS access for drugs + fluids to main bp + temp
- ET tube placement allows for ongoing anesthetic admin/ maint
Order of operation
Efficiency and safety checklists
Order of Operation
Complete Intraoral exam
Chart as you go
+/- Administer local anesthesia (see Holmstrom Ch. 5)
+/- Radiographs - full mouth* (see Holmstrom Ch. 11)
–if extractions needed can be done at any time - do not clean teeth to be extracted*
1.Apply oral rinse
2.Gross calculus removal - supragingival
3.Subgingival calculus removal
4.Power scaling
5.Disclosing and touch ups
6.Polish
7.Rinse
8.Fluoride
What is oral rinse
What’s its purpose
Oral chlorhexidine rinse
●Use an oral solution to avoid bad taste
○0.12%
○0.2% for advanced periodontal disease
●Rinse prior to scaling to decrease aerosolization of bacteria
Checking in the patient on procedure day
A complete hx + dental hx and ability to provide home care
Obtain complete history plus anything pertinent to dentistry
S: Clinical signs?
*Not eating after showing initial interest
Pawing at mouth/rubbing face
Changes in eating/chewing patterns
Uncharacteristic aggression
Gingival bleeding
Part of Complete History and
Development of Treatment Plan
Oral home care history
Yes?
How often?
Types?
No?
Why?
Diet history
Toys
Treat
Types of food
Dealing with dental costs/ estimates
Payment options
Presenting estimates
Client communication
How to create accurate estimates?
How to present the estimate?
How to communicate with the client throughout the procedure?
How to deal with the invoicing drama at discharge time?
How has anesthetic dental safety improved
Safety Improvements
●Complete physical
●Anesthesia tailored to individual patient need
○Safer, smoother induction, intra-op, & recovery
○Goals of preemptive multimodal analgesia
- Decrease patient risk during anesthesia
- Decrease total amount of anesthetic needed
●(i.e. vaporizer flow can be decreased)***
- Prevent dysphoria - emergence delirium/rough recovery
- Post-op pain control
●Supportive care throughout anesthesia and recovery
Why is pre-anesthetic bloodwork necessary
Complete P.E + Kidney and liver functions (UA), cbc/pcv TP, ECG + CXRS
Kidneys filter drugs
Cbc = hemolysis present/ previous + hydration
ECG+ XRS to confirm size/ locations of organs
What is preemptive analgesia
Providing pain control prior to procedure
Reduces pt risk during anesthesia
Decreases amount of anesthetic gas used
Decreases the total volume of drugs given
Prevents dysphoria
Helps control port op pain
Creating individualized anesthetic plans
Patient and drug considerations
Pre-pre-medication considerations
Anxiety - ^ nausea, vomiting
Consider antiemetic agent as “pre-pre-medication”
A2 agonists include- xylazine, dexmedetomidine
Are very sedating
Can cause significant bradycardia
*Usually too short-acting to be beneficial in dentistry
*Emergence delirium
Phenothiazines - Acepromazine
Quite safe at lower doses
Synergistic
Anticholinergic agents
Prevent/treat bradycardia, dry secretions
■Contraindicated:
■A2 agonists
●Ex. Dexmedetomidine
■Very stressed
■Tachycardic
Anesthetic monitoring
Devices used
•Pulse Oximeter
•Capnograph
•ECG/EKG
•Doppler BP or Oscillometric BP
•Temperature
•Monitor the patient’s depth of anesthesia - how?
•ALL patients undergoing anesthesia should receive IV fluids** - why?
Know patient parameters for anesthesia
Why fluid therapy
To maintain blood volume + BP + HYDRATION
Preventing hypothermia
Passive warming*
●Warm water circulation blanket
●Warm air circulation blanket
●Fluid warmer
Watch for heat loss through unexpected sources**
*risk of injury
Managing the airway
The most important thing to manage and monitor when an animal is under general anesthesia
1. CETT
2. Gravity
•Gas exchange only occurs in alveoli
Dead space
CETT
CETT = cuffed endotracheal tube*
Dead space
•Dead space: alveoli not eliminating carbon dioxide properly: affects proper ventilation, accumulates in the ET tube if it is too long**
Choosing the right ET tube
Diameter / how to measure
Length/ landmarks
Measuring landmarks for ET tubes
•Space between nares
–Rough measurement of diameter
–Better to palpate the trachea
•Incisors to cranial end of sternum “manubrium”
–Approximate landmark over tracheal bifurcation ***
Intubation
Intubate
Inflation of cuff
Securing tube
Post extubation clean up
Intubation: always have laryngoscope w/ light available. Hold tube w dominant hand + left hand holds scope and gauze which helps to hold the tongue in place/ not slip. Always pull tongue forward. Structures noted are epiglottis, arythnoid cartilage. Confirm intubation via condensation which should go away. If not in the trachea condensation will remain.
Incisors to manubrium** land marks for measuring ET tube
Endotracheal Tubes
●Securing the tube
●Gauze, umbilical tape, tube ties
●Recycled used IV line set
●Tie behind ears
●Test for leaks
Cleaning post-op
•Inflate cuff
•Wash with warm water and chlorhexidine scrub
•Use spiral brush to clean inside of tube
•Hang to dry
•Storage:
Occlusal assessment prior to intubation
ALWAYS
IntraORAL exam
Protect pharynx
Always start with application of rinse
Your intraoral exam begins on intubation
Pharynx - press down tongue
●Tonsils (usually in their crypts)
●Pharyngeal mucosa
Palatoglossal folds
*Don’t forget: occlusal assessment prior to intubation Evaluate the soft tissues
Examine the lips
●Lip fold dermatitis
●Ulcerations
●Lacerations
●Tumors
Examine buccal mucosa (lines cheeks and lips)
Examine alveolar mucosa (lies against bone)
Caudal cheek lining
“Cheek-chewing lesions”
“Tongue-chewing lesions”
Determine presence of teeth in each quadrant
●Missing teeth should be radiographed
Evaluate the periodontium with a periodontal probe - a miniature intraoral ruler
●Measures sulcus depth, pockets, bone & gingival loss, and helps assess mobility & bleeding
Methods of calculus removal
Techniques
Time on tooth
How to ensure accuracy
Before Scaling Begins
1.Apply Oral Rinse*
Products containing
i.0.12% chlorhexidine
ii.0.2% chlorhexidine
- Supragingival calculus removal
●Thick/heavy deposits removed first “debulking”
■Tartar removal forceps (?)/ Sickle scaler
■Ultrasonic scaling for large deposits of calculus
■Then hand scale; pull stroke in coronal direction
•Modified pen grasp, triangle/forces
•Developmental grooves* - Subgingival calculus removal
○+Newer compressor-driven dental machines have narrower tips available and proper power setting to enable subgingival scaling without changing inserts or adjusting power setting+
○Hand curette is best for deeper pockets*
Check your work
●You will have to turn off the overhead lighting to see the effects of 1. and 2.
Disclosing techniques* to look for missed plaque & tartar
1.Light
2.Solution
3.Blow air from compressor
Polishing teeth
Cup flare
Time on tooth
Polishing
●not cosmetic
●reduces the surface area attachment for plaque and tartar by smoothing the etchings left in the enamel from previously adhered tartar and scaling
*The paste polishes, not the polisher.
*Flare the cup gently for subgingival/sulcus space polishing.
Rinsing
Fluoride tax know 3 reasons
Rinsing
Air/water syringe* (helps visualize sulcus)
●On compressor driven units
●Can cause air embolism and sub-q emphysema
Water filled curved tip syringe
Fluoride* - apply to dry teeth, allow contact time, wipe out excess
3 benefits*
1.Hardens enamel
2.Decreases tooth sensitivity
3.Antibacterial
Dental sealants
Sanos
OraVet
Post op recovery and care
Recover in a safe, quiet, warm area+
–Untie ET tube
–deflate the cuff (unless brachycephalic)
–leave the tube in until gag reflex is present, then remove gently**
–leave in as long as possible especially for brachycephalic breeds*
•Tape/bandage roll trick
●Keep warm
–Dry the patient (hair dryer set to low works)
–Groom face as needed (send pet home
looking better than when they arrived)
●Monitor*
–Q 5 min until extubated
–Q 10 min after extubation
–Heart rate and quality
–Respiration rate and quality
–Temperature
–Mentation
–+/- BG
●Rotate every 15 minutes (if cannot keep sternal)
●Place in bed with the head lowered in readily visible area
●Check vitals every 10 minutes until standing*)
*Extubation time is not related to full recovery and mentation status
●patients are still at risk until return of full mentation and complete ability to stand normally
●(could it be that the increase in mortality in cats is due to us recovering them in an out of the way place? After all, mortality risk is increased in recovery vs. peri-operative…)
*What do I mean by quality?
●Rhythm
●Sound
○Is it dysrhythmic
○Muffled, gurgled, etc.?
Post dental tasks / clean up
Disinfect sink/station, dental machine, and hand instruments*
■All touch points
●Light fixture
●Radiology head tube
●Computer keyboard
○Do not use alcohol on any plastic or rubber parts*
○Best to use dilute chlorhexidine solution
○Follow exact cleaning, maintenance, and storage protocols for your dental machines to keep them in proper working order
●Extracted teeth
○Clean by soaking in hydrogen peroxide
○Save for owner
●Any medications to go home?
○Antimicrobials
•Chlorhexidine oral rinse
○Antibiotics
•Systemic abx usually not necessary* unless immune-compromised/geriatric
•Best time is perio-op (or load w/ Convenia morning of)
–Clavamox (all bacteria types)
–Cephalosporins also good (lower cost as well)
○Analgesics - should be considered for all patients except routine cleaning
•Cats
–Buprenorphine - OTM
–Onsior (robenacoxib; NSAID)
•Dogs - so many choices: NSAIDS, gabapentin
●Complete and/or transcribe dental chart
○Scan and save to EMR
○Copy for owner
●Discharge instructions
○Recheck examination?
○Diet restrictions?
○Toy restrictions?
○Home care restrictions?
○Include before and after photos
Complete chart
Who writes in t he diagnosis section
Doctor
Instrument and dental unit care
Tartar removal forceps
Sickle scaler
Ultrasonic scaling for large deposits of calculus
Hand curette is best for deeper pockets*
Power Scaling
Post-dental ax care instructions
Avoiding overuse of abx
●Any medications to go home?
○Antimicrobials
•Chlorhexidine oral rinse
○Antibiotics
•Systemic abx usually not necessary* unless immune-compromised/geriatric
•Best time is perio-op (or load w/ Convenia morning of)
–Clavamox (all bacteria types)
–Cephalosporins also good (lower cost as well)
○Analgesics - should be considered for all patients except routine cleaning
•Cats
–Buprenorphine - OTM
–Onsior (robenacoxib; NSAID)
•Dogs - so many choices: NSAIDS, gabapentin
Dental home care recommendations
When to focus on brushing
Instructions pertinent to individual
■Limitations on starting home care
■Appropriate home care recommendations
●Brushing
○When to start
●Rinses
●Chews
●Diets
■Next appointment
●This might be a re-check appointment or a forward-booking appointment (notice how you never leave your dentist without a next appointment?)+
Mechanical vs chemical agents for plaque removal
- rinse
-diets
- chews/toys
- powders
- Oral rinses
•Water additives
•VOHC***** Product testing - Diets
•Hills T/D
•Royal Canin
•Eukanuba - Chew toys
- Powders
VOHC product testing
Veterinary Oral Health Council: VOHC authorizes the use of the VOHC Registered Seal on products intended to help retard plaque and tartar on the teeth of animals.
Any chew toy or treat should be monitored under close supervision*
•Anything that you can bend, break in half, crumble, imprint your nail is appropriate
▫Rubber balls, Kongs, and rope toys (cotton not nylon) are appropriate toys
•No
•hooves, bones, pig ears, antlers
•nylabones
•Tennis balls are too abrasive —>
Compliance considerations
Has much to do with making home care accessible/reasonable
•Client’s physical ability
•Patient tolerance
–Can be trained/conditioned
Tidal volume
the amount of air that moves in or out of the lungs with each respiratory cycle
Considerations:
●The calculation is based on weight
●Wt (kg) x 15ml x 6 / 1000 = x (L)
●So if the weight is increased is the TV increased?
Delivering Safest Possible COHAT
Implementing:
Complete PE
Individualized ax protocols
Venous access with IV fluid support (preferably warm)
Airway management
Monitoring
Warming
Supportive care until complete recovery
Infiltration Blocks
•Least effective
•The block is limited to one localized area of the body
•Performed when the animal is under general anesthesia
•Ease of administration
•Technique
•Inject medication into tissues surrounding area needing local anesthesia
Regional Nerve Blocks
•State law regulates if a technician able to perform*
•Advantages
•Blocks the entire quadrant of the mouth = effective
•Great for oral surgery; tumor/jaw removal, major extractions
•Can be repeated if the amount given is under the maximum dose 2mg/kg in dogs and cats
•Ease of administration
•Don’t need a lot of supplies/inexpensive
•Disadvantages
•Loss of feeling and function to the blocked area could lead to self trauma
•Anaphylactic reactions
•Permanent nerve damage
•Toxicity to the skeletal muscle
•Cardiac side-effects
•Difficult to assess efficacy
•Caudal Maxillary “Infraorbital” entering foramen
•Caudal Maxillary “Infraorbital” entering foramen
•Similar to the rostral approach, only advance the needle more caudal into the infraorbital canal
•Rostral Maxillary “Infraorbital”
•Along the gum tissue dorsal to the distal root of 107, 207 (3rd premolar)
•Infraorbital foramen
*Careful not to inject into/thru neuromuscular bundle
•Rostral Mandibular “Mental”
•Infiltrates the inferior alveolar nerve, distal to the mandibular labial frenulum, ventral to the mesial root of the 306, 406 (2nd premolar)
*Very difficult to access d/t labial frenulum - “Don’t bother”
Caudal Mandibular “Inferior Alveolar”
•Advance the needle bevel up intraorally along the mandible caudal to 311, 411 in the dog (3rd molar) or 310, 410 & in the cat (1st molar) 309, into the extraoral notch ventral to the condylar process
•Extraoral technique also possible
•Draw an imaginary line from lateral canthus of eye as a landmark
